<?php

/*
  Template Name: Account info page
 */
?>
<?php get_template_part('inc/header'); ?>
<section class="module row">
     <form id="form-register" class="form-register" role="form">
    <div class="content-red">
        <div class="width70">
        <h3 class="border width105"><?php _e("Account info");?></h3>
        <p><?php _e("You can modify or update any contact information by typing in the correct information in the field boxes and confirm at the bottom.");?>.</p>
       
            <h3 class="border">Personal information</h3>
            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="firstname"><?php _e("First name");?>*</label>
                        <input parsley-required="true" type="text" class="form-control" id="firstname" name="firstname">
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="lastname"><?php _e("Last name");?>*</label>
                        <input parsley-required="true" type="text" class="form-control" id="lastname" name="lastname">
                    </div>
                </div>
            </div>

            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="address"><?php _e("Address");?>*</label>
                        <input parsley-required="true" type="text" class="form-control" id="address" name="address">
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="apt"><?php _e("Apt./Suite");?></label>
                        <input type="text" class="form-control" id="apt" name="apt">
                    </div>
                </div>
            </div>

            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="city"><?php _e("City");?>*</label>
                        <input parsley-required="true" type="text" class="form-control" id="city" name="city">
                    </div>
                </div>

                <div class="col-md-4">
                    <div class="form-group">
                        <label for="province"><?php _e("Province");?>*</label>
                        <select id="province" class="form-control" name="province" parsley-required="true">
                            <option value="18">18</option>
                            <option value="19-24">19-24</option>
                            <option value="25-34">25-34</option>
                            <option value="35-44">35-44</option>
                            <option value="45-54">45-54</option>
                            <option value="55-64">55-64</option>
                            <option value="65 and over"><?php _e("65 and over");?></option>
                        </select>
                    </div>
                </div>
                <div class="col-md-2">
                    <div class="form-group">
                        <label for="city"><?php _e("Postal code");?>*</label>
                        <div class="row">
                            <input parsley-required="true" type="text" class="form-control" id="city" name="city">

                        </div>

                    </div>
                </div>


            </div>

            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="phone"><?php _e("Daytime telephone");?>*</label>
                        <input parsley-required="true" type="text" class="form-control" id="phone" name="phone">
                    </div>
                </div>

                <div class="col-md-4">
                    <div class="form-group">
                        <label for="age"><?php _e("Age");?>*</label>
                        <select id="age" class="form-control" name="age" parsley-required="true">
                            <option value="18">18</option>
                            <option value="19-24">19-24</option>
                            <option value="25-34">25-34</option>
                            <option value="35-44">35-44</option>
                            <option value="45-54">45-54</option>
                            <option value="55-64">55-64</option>
                            <option value="65 and over"><?php _e("65 and over");?></option>
                        </select>
                    </div>
                </div>



            </div>
        </div>
    </div>
        
    <div class="content-green">
         <div class="width70">
            <h3>Log-in information</h3>

            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="email"><?php _e("Email");?>*</label>
                        <input parsley-required="true" type="text" class="form-control" id="email" name="email">
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="email2"><?php _e("Confirm email");?>*</label>
                        <input parsley-required="true" parsley-equalto="#email" type="text" class="form-control" id="email2" name="email2">
                    </div>
                </div>
            </div>
            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="password"><?php _e("Password");?>*</label>
                        <input parsley-required="true" type="password" class="form-control" id="password" name="password">
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="password2"><?php _e("Confirm password");?>*</label>
                        <input parsley-required="true" parsley-equalto="#password" type="password" class="form-control" id="password2" name="password2">
                    </div>
                </div>
            </div>
            
            <input type="submit" class="btn btn-default" value="Register">
            
         </div>
    </div>
    
    </form>
</section>

<?php get_template_part('inc/footer'); ?>